Neonatal infections in South Asia: challenges ahead
Authors: Usha Ram, Faujdar Ram
Journal: The Lancet Global Health (2022)

India has the highest number of newborn deaths worldwide, with 0·5 million deaths within the first month of life annually; Nigeria, Pakistan, Ethiopia, and the Democratic Republic of the Congo together accounted for nearly half of the 2·4 million global newborn deaths in 2019.1WHONewborns: improving survival and well-being.https://www.who.int/news-room/fact-sheets/detail/newborns-reducing-mortalityDate: 2020Date accessed: June 5, 2022Google Scholar Understanding the causes of neonatal infections (eg, bacterial or viral) is crucial to achieve further reductions in neonatal mortality among lagging populations, where infections are a major causes of all neonatal deaths. In The Lancet Global Health, Melissa Arvay and colleagues address this knowledge gap meticulously and help to identify the causes of infections and case management.2Arvay ML Shang N Qazi SA et al.Infectious aetiologies of neonatal illness in south Asia classified using WHO definitions: a primary analysis of the ANISA study.Lancet Glob Health. 2022; 10: e1289-e1297Summary Full Text Full Text PDF PubMed Scopus (1) Google Scholar Arvay and colleagues did a population-based longitudinal study among young infants aged 0–59 days in Bangladesh, India, and Pakistan, aiming to describe the spectrum of infectious causes of acute neonatal illness categorised using the 2015 WHO case definitions of critical illness, clinical severe infection, and fast-breathing only. Arvay and colleagues found that the proportion of illness attributable to bacterial infection was 32·7% in the critical illness group, 15·6% in the clinical severe infection group, and 8·8% in the fast-breathing group; however, an infectious cause was not identified in 58–82% of these infants. For future reductions in neonatal mortality, it is essential to develop simple procedures that facilitate the identification of critical cases among neonates and standardised operating procedures for management, in both clinical and community settings (eg, by health workers such as accredited social health activists [ASHAs] and auxiliary nurse midwives).3Government of IndiaNational Rural Health Mission (2005–2012).https://nhm.gov.in/images/pdf/guidelines/nrhm-guidelines/mission_document.pdfDate accessed: June 1, 2022Google Scholar, 4Government of IndiaNational Health Mission.https://nhm.gov.in/index4.php?lang=1&level=0&linkid=445&lid=38Date: 2017Date accessed: June 1, 2022Google Scholar Most deliveries in India, Bangladesh, and Pakistan now occur in a health facility; however, discharge might happen earlier than recommended due to unavoidable reasons. The recent round of demographic and health surveys showed that 66% of all births in Pakistan5National Institute of Population StudiesPakistan demographic and health survey 2017–18.https://dhsprogram.com/pubs/pdf/FR354/FR354.pdfDate: 2019Date accessed: July 17, 2022Google Scholar and half of all births in Bangladesh6National Institute of Population Research and TrainingBangladesh demographic and health survey 2017–18.https://dhsprogram.com/pubs/pdf/FR344/FR344.pdfDate: 2020Date accessed: July 17, 2022Google Scholar in 2017–18 occurred in a health facility. In 2019–21,7International Institute for Population SciencesNational family health survey 5, 2019–21.http://rchiips.org/nfhs/NFHS-5Reports/NFHS-5_INDIA_REPORT.pdfDate: 2022Date accessed: June 5, 2022Google Scholar 20% of women in India who had a vaginal delivery stayed in a health facility for less than 24 hours. For caesarean section deliverys, 12% of women stayed in the health facility for less than 3 days; this includes 4% of women who stayed for less than 6 hours. These proportions were much higher in Pakistan5National Institute of Population StudiesPakistan demographic and health survey 2017–18.https://dhsprogram.com/pubs/pdf/FR354/FR354.pdfDate: 2019Date accessed: July 17, 2022Google Scholar and Bangladesh.6National Institute of Population Research and TrainingBangladesh demographic and health survey 2017–18.https://dhsprogram.com/pubs/pdf/FR344/FR344.pdfDate: 2020Date accessed: July 17, 2022Google Scholar For example, in 2017–18, 84% of women in Pakistan and 41% of women in Bangladesh who had a vaginal delivery stayed in a hospital for less than 24 h. Furthermore, 26% of women in Pakistan and 2% of women in Bangladesh who had a caesarean section delivery stayed in a health facility for less than 3 days. To explore the potential implications of the facility-to-home transition in India, we analysed age-specific mortality rates for the first week after birth from five National Family Health Survey7International Institute for Population SciencesNational family health survey 5, 2019–21.http://rchiips.org/nfhs/NFHS-5Reports/NFHS-5_INDIA_REPORT.pdfDate: 2022Date accessed: June 5, 2022Google Scholar rounds. Our analysis indicates that, in India, the age-specific mortality rates during the first week of life remained unchanged until 2005–06. The mortality rates showed notable improvement after 2005–06, when several innovations to improve maternal and newborn survival were introduced. However, a crucial point emerging from this analysis is that the mortality rate on day 3 is substantially higher than on day 2 in all the surveys, suggesting a poor transition of care from hospital to household (figure). This finding calls for special attention to the management of newborn health status when the newborn baby is moved from the health facility to the home. This attention is crucial, as the social settings (including maternal and household characteristics), are often poor among the vulnerable populations that continue to show higher neonatal mortality rates. Consequently, health system improvements might play a small role in future reductions in neonatal mortality in India. Multipronged efforts, including an effective, low-cost health system combined with a responsive programme for dealing with social determinants locally might need greater attention. Given that the causal factors of neonatal infections do not have specific symptoms, identifying such factors is difficult. By using cohort data on infants aged 0–59 months (healthy controls and those with possible serious bacterial infection) in Bangladesh, India, and Pakistan, the Arvay study examines the relevance of WHO classifications of critically ill, clinical severe infection, and isolated fast breathing. The study highlights the limitations and non-specificity of the WHO case definitions for infectious causes of illness, and advances our understanding of infection among critically ill neonates in times when neonatal mortality reduction is a global challenge. This study is a crucial step in the right direction; however, more rigorous research is required in this area. We declare no competing interests. Infectious aetiologies of neonatal illness in south Asia classified using WHO definitions: a primary analysis of the ANISA studyOur modelled results generally support the revised WHO case definitions, although a revision of the most severe case definition could be considered. Clinical criteria do not clearly differentiate between young infants with and without infectious aetiologies. Our results highlight the need for improved point-of-care diagnostics, and further study into neonatal deaths and episodes with no identified aetiology, to ensure antibiotic stewardship and targeted interventions. Full-Text PDF Open Access